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Approval of physical therapy continuing education credit varies by state. Confirm approval with your state's licensing agency before you take the course for CE credit. See Physical Therapy CE Approval for more information.
Course Availability: Expires November 1, 2018. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. Medical Disclaimer Legal Disclaimer Disclosures
NOTE: This course is not approved for PTs/PTAs in Florida.
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COURSE OBJECTIVE: The purpose of this course is to enable healthcare professionals to identify the causes, symptoms, stages, management, and prevention of job-related stress, particularly burnout.
Upon completion of this course, you will be able to:
Healthcare professionals are challenged on a daily basis with a variety of stressors as they care for patients. These job-related stresses can take a toll on the mind and body of these professionals, which in turn may affect the quality of patient care and outcomes. Work-related stress may also impact job satisfaction, workforce stability, and safety in the healthcare environment (Van Bogaert et al., 2013).
Nurses, for one, have identified stress and overwork as one of their top concerns within the profession (ANA, 2011). Work schedules that include long shifts and insufficient staffing are two factors identified by nurses that increase stress levels. Nurses and other professionals need to be aware of the stresses associated with intense clinical settings and challenging work schedules.
Healthcare professionals work in demanding situations, hold high expectations for themselves, and believe they should be able to handle anything no matter what the challenge. Fortunately, job-related stress is both “treatable” and preventable. Professionals can learn to cope with stress and burnout by gaining an understanding of stress and stressors, recognizing the signs and symptoms of job burnout, acquiring skills to manage its destructive effects, and preventing its occurrence in the future.
“Stress” is the term used to describe a variety of physiological and psychological stimuli that cause a physiological response. The idea of stress began with the pioneering work of Walter Cannon (1871–1945). He investigated the sympathetic nervous system as it reacts to heat and noticed that the body responds in a predictable sequence.
The stress response was first described in 1956 by Hans Selye. In his research, he separated the physical effects of stress from other physical symptoms, observing that patients suffered physical effects not caused directly by their disease or by their medical condition. Selye found that stressors may be physical (such as infection, injury, and pain) or psychological (such as fear, anger, and sadness).
He identified what he called a general adaptation syndrome, whereby the body seeks to maintain homeostasis, or balance. He divided his general adaptation syndrome into three stages:
Stress can have a major impact on the physical functioning of the human body. It raises the level of adrenaline and corticosterone, which in turn increases the heart rate, respiration, and blood pressure and puts more physical stress on bodily organs. In the short term, this allows a person to perform at levels beyond their normal limits. But once exhaustion is reached, even the strongest motivation loses its effect.
Exhaustion sets in as the individual fails to adapt to stressors and becomes exhausted.
Source: Adapted from Selye, 1956.
Lazarus (1966) expanded our understanding of stress and the ways people deal with it when he observed that, when individuals view a new or evolving situation, they first decide whether it is a threat. He called this primary appraisal. Then, as people further monitor a threat, they evaluate their ability to cope with it by what Lazarus called secondary appraisal. In this second step of appraisal, individuals judge themselves unable to handle the situation and withdraw.
Professionals working in intense clinical areas where the stakes are high are more prone to believe they “should” be able to handle anything and attempt to do so, no matter how great the cost to their body. These individuals are at high risk of reaching the end stage of stress: exhaustion.
Instead of persisting until they reach the state of exhaustion, healthcare professionals can learn more effective coping strategies, become self-aware, acknowledge their own limitations, and acquire emotion-regulation and problem-solving skills.
Leaders can provide physical and emotional support for staff members as a way to show support and acknowledge the value of their role and understand the stressful nature of their work. Work-life balance programs can provide a focus on wellness resources with strategies to prevent and manage the stress of working in an intense healthcare environment.
Carol Williams, RN, is a team leader in a locked unit at the state psychiatric hospital. Because of recent staff shortages, she has been required to work double shifts with dangerously high patient-to-staff ratios. She previously felt good about her job and confident that, even though her patients were severely impaired, she was making a difference in their lives. Lately, however, she has been emotionally and physically exhausted and can’t seem to relax. She has been having “nervous headaches,” stomach pains, and mood swings, exploding in a rage of anger one moment and bursting into tears the next.
To cope with the stress, Carol has become distant and detached from her team members and patients. She does not actively engage with her coworkers during her shift and has insufficient time to meet all of the needs of the patients. She has expressed her frustration and anger during nursing handoff when discussing cases, verbally accusing her coworkers of leaving work undone for her shift.
Because of her behaviors, Carol’s coworkers have complained to their supervisor about her attitude. Carol knows she is not managing the situation well, but the stress of the job and lack of support from her supervisor are wearing her down. She feels angry, trapped, insecure, inadequate, and a bit fearful she will lose her job.
Carol felt overworked and underappreciated. At some point she realized (primary appraisal) that she was overpowered by an entrenched bureaucracy and out-numbered by an unsympathetic staff. She knew she was not performing at the level she expected of herself, and she felt guilty, insecure, inadequate, and fearful she might lose her job.
To cope, Carol began using a strategy she had seen others employ: detachment and dissociation. After a while she realized (secondary appraisal) her method of coping was not solving the problem; the situation was only getting worse and she was becoming emotionally and physically exhausted.
Healthcare professionals may experience a variety of stress responses. Common forms of such stress include compassion fatigue, vicarious trauma, and burnout.
Within both healthcare literature and common usage, these terms are sometimes used interchangeably. In general conversation, this may not be an issue, especially if the intent is to share personal experiences or to express concern or empathy. But healthcare providers are more likely to be seeking to understand their reactions or to formulate personal care or prevention plans. In this case, understanding the subtle differences is important.
Compassion fatigue is the profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate between caregiving situations (WHP, 2007). Compassion fatigue in healthcare professionals is typically described as losing the capacity or interest in being empathetic or bearing the suffering of one’s patients. It has also been referred to as secondary traumatic stress. However, the term compassion fatigue has not been formally defined within nursing practice (Boyle, 2011).
Certain healthcare professionals—for instance, acute care nurses or first responders—can be especially vulnerable to this form of workplace stress due to their ongoing work with patients who are facing severe pain, tragedies, and issues of life and death. The very empathy that often motivates such people to enter the healing field can, if not recognized and planned for, make them victims as well.
For healthcare providers who work in intense situations such as responding to severe trauma, a phenomenon called vicarious trauma is also often observed. Unlike direct or experienced trauma, vicarious trauma is the result of changes in a healthcare provider’s worldview due to empathic engagement with victims (CERT, 2011). This type of trauma is comparable to posttraumatic stress disorder (PTSD), which is a response including feelings of fear, helplessness, and shock as a result of a traumatic event (Sabo, 2008).
Among the physical manifestations of vicarious trauma are anorexia and direct gastrointestinal (GI) symptoms such as nausea, stomach pain, and diarrhea. If the person reacts to this GI upset by not eating or eating less than usual, fatigue and reduced energy can result. Paradoxically, both insomnia and hyperactivity are also possible. Headache and chest pain may present.
Psychological signs may present as exaggerated forms of a person’s usual behavior or as reactions not usually seen, at least in the workplace. As the situation continues, these responses may become more frequent and/or stronger and/or require less and less to trigger them.
Among the common presentations of vicarious trauma are the following:
Sara, an EMT, and Josie, an emergency department (ED) nurse, were both recently involved in caring for victims of a shooting incident. The perpetrator shot not only the intended victim but also five bystanders.
Sara was a first responder to the shooting scene and found herself strongly shaken by her encounter with one of the critically injured bystanders, who resembled her younger sister. Despite post-incident counseling, continuing her meditation practice, and taking time off with her family, she has not yet worked through her feelings. She also finds herself unable to concentrate, experiencing images of her younger sister as the shooting victim, and avoiding her family and friends.
Josie was on duty in the ED on the day of the shooting and cared for several of the victims. In addition to being the trauma team leader for a resuscitation of one patient, she held another patient’s hand as she died. Caring for so many seriously injured patients hour after hour, day after day has begun to take a toll on Josie. She’s unable to recharge and has begun feeling detached from her patients, a loss of interest in ordinary activities, and insomnia.
Sara is experiencing vicarious trauma as the result of both her ongoing exposure to traumatized patients and this particular shooting victim’s likeness to her sister. A unique symptom to this form of job-related stress is Sara’s recurring, intrusive images. Josie, on the other hand, is displaying symptoms more characteristic of compassion fatigue brought about by her constant exposure to suffering patients and characterized by her loss of feeling for her patients.
Smith and colleagues (2015) describe job burnout as “a special type of job stress, a state of physical, emotional, or mental exhaustion combined with doubts about [one’s] competence and the value of [one’s] work.” It is a gradual process by which people detach from meaningful relationships in response to protracted stress and physical, mental, and emotional strain. The result is a feeling of being drained, unproductive, and having nothing more to give. People working as healthcare professionals are especially vulnerable to job burnout.
Burnout generally occurs in four stages:
Physical and emotional exhaustion are caused by a heavy and unrealistic workload, stress-producing time limitations, inadequate rest and sleep, unfair work assignments, and lack of respect from managers. Under such stresses, the pineal gland produces melatonin, which disrupts the sleep-wake cycle, further contributing to fatigue.
As individuals become more and more overwhelmed at work, their sense of competence decreases and feelings of shame increase. They discount past accomplishments, even in the face of objective evidence. At this stage of burnout, individuals may sigh heavily, breathe deeply, and experience a profound sense of loss, uncertainty, and vulnerability.
As a defense against feelings of vulnerability and inadequacy, many individuals decide there is only one thing to do: protect themselves. To do so, they become cynical and callous. They develop an “attitude,” saying to themselves, “I can’t let them get to me. I’ve got to take care of myself!” At first, the strategy works because other people tend to avoid unpleasant or brusque individuals. Predictably, the strategy often does not work because healthcare workers are typically uncomfortable being “bad guys.” They have usually thought of themselves as gracious and accommodating, and now they feel angry and rejected.
At the fourth stage of burnout, coping skills are at their lowest level. People are worn down, vulnerable, and exhausted. Their defenses have begun to fail. Old hurts and upsetting memories of past failures and poor choices begin to seep through their protective shield. Every area of life is affected. The smallest of slights and least important omission makes them respond intensely. When someone else is recognized instead of them, the smoldered coals of sibling rivalry reignite. Nothing is going well. Everything seems to be going wrong (Smith et al., 2015).
|COMPASSION FATIGUE||VICARIOUS TRAUMA||BURNOUT|
|Source: Sabo, 2011.|
|Lack of opportunity to refuel and regenerate between caregiving situations||Repetitive exposure to others’ traumatic experiences||Low job satisfaction; feelings of being powerless and overwhelmed|
|Extreme other-directed attitude||Immersion in helping traumatized victims||Workplace environment|
|Detachment and decreased intimacy; somatic complaints||Somatic complaints; intrusive imagery||Negativity (outwardly and inwardly directed)|
|Negative Effect on Worldview|
|Loss of Ability to Feel Compassion|
Dan Ramirez, LPN, works in a long-term care facility owned and operated by a for-profit company, and he’s found that the administration’s primary concern seems to be keeping the beds full and the costs low. Dan’s supervisor is an RN, but she provides no patient care, while Dan gives medications, provides wound care, writes care plans, maintains patient records, and more.
At first, Dan felt challenged and proud of his ability to manage so many responsibilities. Then one attendant went on sick leave and another quit, leaving the day shift seriously short-staffed. Dan sympathized with his supervisor’s difficulty finding qualified help and assumed the duties of the absent attendants, expecting the situation would last only a few days or weeks. Soon he found himself working overtime almost every day and felt obliged to “do it all.”
As the weeks went on Dan became more and more fatigued, frustrated, and irritable (physical and emotional exhaustion). He had trouble sleeping and began self-medicating with alcohol. Then, one day, he made a medication error. Fortunately, the patient was not harmed, but the physician scolded him loudly in front of other staff members. Dan was humiliated. He began to doubt his abilities and to think of himself as a professional failure, an imposter (shame and doubt). He even began to question his decision to become a nurse. As his self-confidence decreased, Dan’s self-doubt and detachment increased, and he began distancing himself from his coworkers, family, and friends.
Dan became more and more irritable, cynical, and callous. He felt tired all the time, suffered frequent headaches, and barely dragged himself to work each day. One afternoon he hurt his back lifting a patient and went out on sick leave. After months of physical therapy, surgery, and then more physical therapy, Dan went back to work part-time, but he just couldn’t keep up the pace. He felt like a failure, unable to carry on. On the verge of collapse, he quit his job, disillusioned with the nursing profession and the entire healthcare system.
Dan’s case illustrates the four stages of burnout. By assuming the duties of the absent attendants rather than assertively addressing the issue of inadequate staffing with his supervisor, Dan became physically and emotionally exhausted. The resulting impacts on his job performance soon caused him feelings of shame and doubt. This in turn caused him to become cynical and callous, finally leading to a sense of failure and quitting his job entirely.
Burnout does not happen overnight. It is a gradual process occurring slowly over time. It is important to recognize the early symptoms and warning signals for burnout. The signs and symptoms may be physical, emotional, or behavioral.
Job burnout is caused by many interactive factors; some are due to the personality and lifestyle of workers and some are due to the work environment. These may include:
When individuals reach the fourth stage of burnout—failure, hopelessness, and collapse—they cannot go on. Strategies to recover from the stress of burnout may include:
Burned-out individuals may find that they have used up their emotional and physical reserves. When people acknowledge they are burned out, they need to take a break and get help. It is important that healthcare professionals realize that taking care of themselves is the most important step for them to continue to care for others.
It is normal to feel anxious when one needs help from a supervisor or colleague, because the individual may receive unwanted advice, shaming, or rejection. All relationships benefit when people admit they are struggling and express their needs. This allows others to do the same. It is important for healthcare professionals to acknowledge when they are hurting and to return support and caring to colleagues as well as patients.
As burned-out individuals scrutinize each part of their story, it is not unusual to find that one or more of the pieces is a jagged, unhealed, unresolved loss. That loss may be their reputation, cherished loved one, a prized possession, their health, an opportunity, or some other treasured thing. When unresolved bereavement is a factor in burnout, individuals need to engage in what is called grief work. This is an emotional process by which bereaved individuals re-experience their loss, loosen the ties to it, and gradually adjust to life without the cherished person, item, or situation.
To facilitate the grieving process, individuals set aside a time to grieve during which they allow themselves to re-experience the loss. At the end of the allotted time, they close the book, dry their tears, and return to activities of daily living. They do this repeatedly and over time. Such grief-work facilitates a separation from the lost possession.
When individuals are in positions of high stress and overwhelming anxiety, they may not realize just how stressed they have become. They may insist they can “handle it,” whatever “it” may be. Over time, they become distraught, distrustful, and skeptical of the goodwill of others. They may attempt to protect themselves with a defense of cynicism and denial. This does not work because denial is a lie they tell themselves.
When people confront the truth and admit their exhaustion, cynicism, and vulnerability, they open the door to health and healing. In fact, truth does set people free. As soon as they accept themselves just as they are, honestly admitting their frailty, failures, and fatigue, they are relieved of the burden of being perfect and are able to replace denial, cynicism, and fear with acceptance, joy, and hope.
Often, individuals who are burned out have been trying to be super-beings. They have been strong and accommodating, worked diligently, and persevered no matter what was asked of them. Things are different now. When people reach the end-stage of burnout, they must admit that they are not super-beings; they are human beings and have limits. These limits may be different from other people, but they are real and they are theirs. As with denial, when individuals admit they are less than perfect, they are wonderfully liberated. In the future, they will be better equipped to heed the signs and symptoms of emotional and physical exhaustion.
Setting personal boundaries means knowing who you are, where you begin and where you end, and when to say, “This is my responsibility and that is yours.” Typically, healthcare professionals are empathetic, understanding, and nurturing. All too often, however, they have weak boundaries and easily merge their identities with others. Such mergers are not healthy; they burden the individual, contribute to burnout, and deprive the other people of autonomy and self-respect. When individuals fail to maintain personal boundaries, they may exercise inappropriate control over others and become unwittingly codependent.
Self-nurturance means caring for oneself. When people who are burned out finally stop what they are doing and get help, they are beginning to nurture themselves. Self-nurturance is a conscious awareness of personal needs, with the focus on taking responsibility for oneself.
Ultimately, self-nurturance is a measure of maturity. It means taking care of one’s own basic needs for survival, safety and security, belonging and affection, respect and self-respect, and self-actualization. Practically speaking, self-nurturance means providing oneself with adequate sleep, a balanced diet, physical and mental exercise, human companionship, and self-actualizing activities.
Healthcare professionals may have experienced high levels of stress for such a long time that they no longer know how to relax. Their home and work environment may be so demanding that they can no longer take time for themselves, or they may have felt guilty when they took a moment to relax.
The following stress-reducing tips may assist in maintaining work-life balance:
To recover from burnout or prevent burnout, many individuals find the regular practice of a relaxation exercise of great value.
Problem solving is especially difficult for individuals who are burned out because they are emotionally and physically exhausted. Nonetheless, when burned-out individuals take a break, get help, grieve for losses, confront denial and cynicism, acknowledge limitations, establish personal boundaries, nurture themselves, and use stress-reducing strategies, they are ready to begin solving problems and prevent burnout in the future.
The four steps of problem solving are as follows:
After graduating from physical therapy school and passing her board examination, Sierra began her clinical practice in a small, critical-access hospital in a rural county. She looked forward to gaining experience and mentorship from the rehab director, who was also a physical therapist. Soon, however, the rehab director abruptly left the department when his wife accepted a job in another city.
While the hospital searched for a new rehab director, Sierra was on her own managing all physical therapy consults in both the inpatient and outpatient sections of the hospital as well as most of the day-to-day running of entire rehab department. She increasingly found herself staying at work until after 9 p.m. in order to make sure that all patient consults and treatments had been addressed and all required paperwork and billing were completed.
At home, Sierra began to have trouble sleeping at night and could never seem to stop worrying about things she may have left undone at the hospital that day. Her fiancé, Jamal, began to notice that she was growing shorter-tempered, frequently exploding over things that never would have bothered her before, and refusing invitations from their friends in order to stay late at the hospital.
One evening Jamal became concerned that Sierra was not yet home from work and was not answering her cellphone. Finally, he drove to the hospital and found Sierra surrounded by patient files, frantically completing notes. When Jamal walked into the room, Sierra burst into tears and said, “I don’t think I can do this anymore.” Jamal drove Sierra home, gave her dinner, and drew her a hot bath. Then, they sat down on the sofa, and Sierra admitted that she was in over her head. She could not, she realized, continue to handle the entire PT caseload and keep the rehab department running. She was at risk of burnout and would have to take action to address her situation and recover her balance.
The next day, Sierra met with the hospital administrator and told her that she simply could not continue to manage both the clinical caseload and the running of the rehab department, especially since she was still only being paid as an entry-level staff therapist. Sierra explained that, while she took patient care and the needs of the region very seriously, her own health had started to suffer and that she was no longer willing to keep running the department on her own. She asked the administrator if a compromise could be reached, or if she should begin seeking employment elsewhere.
The administrator, recognizing signs of employee burnout and not wanting to risk losing Sierra, agreed to contact a staffing agency and arranged for a locum PT to join the department on a temporary basis until a permanent rehab director could be found. Sierra agreed to keep handling some of the administrative tasks normally covered by the rehab director on a short-term basis, with the caveat that she be offered fair financial compensation for doing so.
With a locum PT now handling most of the day-to-day patient caseload, Sierra returned to working a fairly typical 40-hour workweek most of the time, although she occasionally stayed late to work on administrative duties. Sierra and Jamal used some of the extra money from her raise to enroll together in a weekly yoga and meditation class at the local YMCA.
Sierra took several actions to address and recover from burnout. First, she acknowledged her limitations and established boundaries by letting the hospital administrator know that she could not—and would not—run the rehab department on her own. She employed a problem-solving approach by setting an objective of increased pay for her increased responsibilities and by leveraging the administrator’s ability to make a change to her situation. Sierra also reduced her stress by enrolling in a yoga and meditation class.
The causes and prevention of burnout are interrelated, involving both workers who suffer burnout and the environment in which they work. To prevent burnout, individuals need to identify and resolve stress-producing issues, and employers need to identify and address workplace stressors that create burnout. When healthcare professionals and their organizations address these matters, both benefit. Individuals experience less burnout and organizations maintain a staff that provides patients with the highest quality care.
When employees suffer burnout and become cynical, detached, and exhausted, productivity is reduced, standards are compromised, and the reputation of the organization is diminished. This is particularly true in service industries such as those that provide healthcare.
To prevent burnout in employees, managers in organizations need to identify the specific institutional issues that create stress and take measures to alleviate them, namely:
Management can ask—and act upon—these questions as a strategy to prevent caregiver burnout:
Healthcare professionals can prevent job burnout by addressing the same causal factors as employers. This includes asking the following questions:
Sandra is the staff development coordinator for a volunteer outreach clinic as well as the manager of the clinic’s vaccination program. This is in addition to her part-time job at a family practice office. She has also been approached about overseeing an annual health and wellness fair at her church and is seriously considering accepting the position.
Recently, the outreach clinic has been mandated to provide all volunteers with safety and diversity training similar to that required for county employees working in comparable positions. The clinic is given a two-month window in which to complete the training, and Sandra must oversee this effort.
With all that is on her plate, Sandra realizes that her work responsibilities, in addition to her personal and family life, have become overwhelming and that she is perilously close to burning out (primary appraisal). Sandra looks at her behavior and realizes there are warning signs she has ignored: her sleep is not restorative, she is much less motivated than usual, she is unusually irritable, and she has stopped doing the “fun” things that were her recreational outlets (secondary appraisal).
At the monthly clinic staff meeting, Sandra grumpily admits that she has made very little progress inplementing the volunteer training effort. Since both the tenor of her response and her reported lack of progress are not “typical Sandra,” her manager, Phong, calls a meeting with Sandra to discuss strategies. At the meeting, they write out all of the tasks currently on Sandra’s plate, both those associated with the clinic and others.
Phong remembers that Jorge, a new volunteer, is the trainer for the county afterschool program and recently conducted similar training. She decides to assign Jorge to help Sandra and says she will set up a meeting between the two of them so that they can pool their skills and ideas.
Sandra also admits that she does not really want to volunteer for her church’s health fair but would feel guilty saying no since she was told that she was “the only one who could do a good job of it.” Sandra realizes this is not the case and identifies several others in her church who have the demonstrated ability to take on this project, resolving to recommend one of them to the pastor.
Sandra leaves the meeting with her manager knowing that she has dodged the bullet of burnout by being proactive in addressing her situation. She resolves to implement the ideas she and Phong came up with, both taking advantage of Jorge’s help with the volunteer training and declining to organize the church health fair. She also decides she will talk with her husband about finding ways to have fun together.
Sandra and her employer both took preventative steps to avoid her burning out. Together, they assessed her workload and came up with a strategy involving her getting help from a coworker and reducing her other personal commitments.
Stress and burnout significantly affect individual healthcare professionals, the organizations for which they work, and the people to whom they give care. These conditions are especially common in healthcare professionals because of the demanding nature of the work, the personal characteristics of caregivers, and the expectations of the managers of healthcare organizations.
Job-related stress and burnout directly affect both the healthcare professional, the quality of patient care, and healthcare institutions. By understanding and addressing their causes, job-related stress can be reduced. Both individual and institutional strategies can also be employed to prevent burnout, thereby creating a healthier environment for both healthcare professionals and patients.
Holistic Stress Management for Nurses (American Holistic Nurses Association)
Job Burnout (Mayo Clinic)
Preventing Burnout (Helpguide)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
American Nurses Association (ANA). (2011). 2011 ANA health and safety survey. Retrieved from http://www.nursingworld.org
Attig A. (2010). How we grieve: relearning the world (2nd ed.). New York: Oxford University Press.
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Boyle D. (2011). Countering compassion fatigue: a requisite nursing agenda. Online Journal of Issues in Nursing, 16(1). Retrieved from http://www.nursingworld.org
Community Emergency Response Team (CERT). (2011). CERT basic training participant’s manual: unit 8, terrorism and CERT. Retrieved from https://www.fema.gov
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Mayo Clinic. (2012). Job burnout: how to spot it and take action. Retrieved from http://www.mayoclinic.org
Sabo BM. (2011). Reflecting on the concept of compassion fatigue. Online Journal of Issues in Nursing, 16(1). Retrieved from http://www.nursingworld.org
Sabo BM. (2008). Adverse psychosocial consequences: compassion fatigue, burnout and vicarious traumatization: are nurses who provide palliative and hematological cancer care vulnerable? Indian J Palliat Care, 14, 23–9. Retrieved from http://www.jpalliativecare.com
Selye H. (1956). The stress of life (Rev. ed.). New York: McGraw-Hill.
Smith M, Segal J, & Segal R. (2015). Preventing burnout: signs, symptoms, causes, and coping strategies. Retrieved from http://www.helpguide.org
Todaro-Franceschi V. (2013). Compassion fatigue and burnout in nursing. New York: Springer.
Van Bogaert P, Kowalski C, Weeks SM, Van heusden D, & Clarke SP. (2013). The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care: a cross-sectional survey. International Journal of Nursing Studies, 50, 1667–77.
Worden W. (2009). Grief counseling and grief therapy: a handbook for the mental health practitioner (4th ed.). New York: Springer.
Workshops for the Helping Professions (WHP). (2007). Compassion fatigue Q&A. Retrieved from http://home.cogeco.ca